Pharmacy Prior Authorization Criteria

Commercial MEDLIMIT CDUR Criteria

Indications for Prior Authorization

Criteria

Requested opioid pain medication

Administrative

Length of Approval: 1 Time(s)
For diagnosis of Level of Care Change

• Provider confirms replacement prescription(s) of opioid medication(s) is needed because the patient is physically changing locations and cannot take their prescription with them [such as admission to a long term care (LTC) facility]

Requested opioid pain medication

Administrative

Length of Approval: 12 Months to override MME edit
For diagnosis of Cancer-Related Pain or Sickle Cell Anemia

• Confirmation opioids are being used for the treatment of cancer-related pain or sickle cell anemia

Requested opioid pain medication

Administrative

Length of Approval: 12 Months to override MME edit
For diagnosis of Hospice, Long Term Care, or End-of-Life Care Enrollment

• Patient is currently enrolled in hospice, end-of-life care, or resides in a long term care facility

Requested opioid pain medication

*MME is calculated using all of the member's current opioid prescriptions *Note: Ask provider, "Will there be a dose escalation in the patient's opioid utilization in the next 90 days?" If yes, approve MME level 90 daily MME above the rejected level.

Administrative

Length of Approval: 12 Month(s)
For diagnosis of Other Pain

• A written or verbal supporting statement is received from the requesting prescriber attesting that in his/her clinical judgment, the requested dose exceeding the current cumulative morphine milligram equivalent (MME) threshold* is medically required

P & T Revisions

2024-09-20, 2023-10-04, 2022-10-05, 2022-01-11, 2021-10-06, 2021-05-20, 2020-10-30, 2020-10-07, 2020-07-01, 2020-04-01, 2019-10-16

References

1. Agency Medical Directors Group. Interagency guideline on opioid dosing for chronic non-cancer pain: An educational aid to improve care and safety with opioid therapy. Available at: http://agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed August 31, 2023.
2. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10:113-130.
3. Jamison, Robert. Substance abuse treatment for high risk chronic pain patients on opioid therapy. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 7/22/2011. Available from: http://clinicaltrials.gov/ct2/show/NCT00988962. NCT00988962. Accessed August 31, 2023.
4. Manchikan L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part 2 - Guidance. Pain Physician. 2012; 15:S67-S115.
5. Micromedex Healthcare Series. Available at http://www.thomsonhc.com/home/dispatch. Accessed August 31, 2023.
6. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1external icon.

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End Notes

1. All opioid medication edits are subject to review and modification (either to increase or decrease existing MME Limits) based on an Exception request received from the member or the member's provider. The decision to remove, modify, or retain an existing restriction on opioid pain medications will be based on evidence of new clinical information which is documented in the form of a written supporting statement received from the prescriber and which contains all of the required elements as outlined in the criteria above.

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Revision History

• 2024-09-20: 2024 Annual Review. Pain due to cancer diagnosis was updated to "Cancer-related pain."
• 2023-10-04: Annual review: Background updates.
• 2022-10-05: Annual review: Background updates.
• 2022-01-11: Annual review: Background updates.
• 2021-10-06: Annual review: Background updates.
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2020-10-30: Added hospice, sickle cell anemia, long term care facility residency to criteria.
• 2020-10-07: Annual review: Background updates.
• 2020-07-01: Guideline name change
• 2020-04-01: Changed all MED references to MME.
• 2019-10-16: Annual review - updated note section.

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